DSM-IV Religious and
Spiritual Problems

Lesson 1 Background of
Religious or Spiritual Problem (V62.89)

Mental Health and
Spirituality The mental health field has a heritage of 100 years
of ignoring and pathologizing spiritual experiences and
religion. Freud promoted this view in several
of his works, such as in Future
of an Illusion wherein he pathologized religion as:

A system of wishful illusions together with a disavowal
of reality, such as we find nowhere else...but in a
state of blissful hallucinatory confusion.

Freud also promoted this view in Civilization
and Its Discontents, where he reduced the "oceanic
experience" of mystics to "infantile helplessness" and
a "regression to primary narcissism." The
1976 report Mysticism: Spiritual Quest or Psychic Disturbance
[1] by the
Group for the Advancement of Psychiatry (GAP) followed
Freud's lead in defining religion as a regression,
an escape, a projection upon the world of a primitive
infantile state.

Albert
Ellis,PhD is the creator of Rational Emotive Therapy,
the forerunner of cognitive modification approaches
now widely used in cognitive-behavioral therapies.
In a recent (2001) interview, Ellis
stated:

Spirit and soul is horseshit of the worst sort. Obviously
there are no fairies, no Santa Clauses, no spirits.
What there is, is human goals and purposes...But a
lot of transcendentalists are utter screwballs.

In addition to his bias against spirituality as a constructive
element in health, in many other of his writings he has
also derided religion:

The elegant therapeutic solution to emotional problems
is quite unreligious ...The less religious they [patients]
are, the more emotionally healthy they will tend to
be" [2]

BF
Skinner,PhD, the psychologist who pioneered understanding
of behavior modification principles that are the other
half of cognitive-behavioral therapies, did not publish
a single word on the topic of spirituality. He approached
humans as stimulus response boxes with varying behaviors
that depend on environmental contingencies. Skinner's
psychology gave no attention to inner experience, which
does leave out a lot of what makes people human beings.
However, Skinner's implicit views on religion can be
gleaned from the novel he wrote about a Utopian community, Walden
Two. In this novel, one member describes religion
as:

an explanatory fiction, of a miracle-working mind...superstitious
behavior perpetuated by an intermittent reinforcement
schedule

These founders' views on religion and spirituality have had a profound influence
on the clinical approach to these issue. M.
Scott Peck, MD, author of The
Road Less Traveled, highlighted the disastrous clinical consequences
for all the mental health professions:

Traditional neglect of the issue of spiritually has
led to five broad areas of failure:

occasional
devastating misdiagnosis; not in frequent
mistreatment; an increasingly
poor reputation;inadequate research
and theory; and a limitation
of psychiatrists' own personal development.

As a result, research on both psychopathology
and mental health has largely ignored religion.

Surveys conducted in the United States consistently show a "religiosity
gap" between the general public and patients who in many surveys report
themselves to be more highly religious and to attend church more frequently
than mental health professionals.

The pathologizing and ignoring of religion and spirituality
has also resulted in clinical insensitivity towards
individuals who present with religious and spiritual
problems and issues.

These negative views of religion and spirituality are
not warranted in light of recent studies showing no association
between religiosity and psychopathology in the nonpatient
population. Controlled studies have also found that "The
notion that religion exerts a negative influence on mental
health in patients was not generally supported by our
findings" (Pfeifer
and Waelty, 1995). In fact, a meta-analysis of religiosity
and mental health found them to be positively related.
Church-affiliated individuals showed greater happiness
and satisfaction with marriage, work and life in general.
Studies of the self-reported relationship between quality
of relationships with divine others (e.g., Christ, God,
Mary, etc.) and several measures of well-being also found
a significant positive association. While there does
seem to be a relationship between religiosity and psychopathology
in the seriously mentally ill, for the vast majority
of the population, spirituality and religion are associated
with positive characteristics of mental health. Similarly,
mystical experiences and spiritual practices are positively
associated with mental health variables.

______ viewed religious beliefs as fantasies that prevent people from coming to terms with how things really are.

a) C G Jung

b) Sigmund Freud

c) Albert Ellis

d) b and c

Record your answers for later insertion into the Quiz.

History of the DSM-IV Proposal To redress the lack of sensitivity to religious and
spiritual problems, the course author along with two
psychiatrists (Francis Lu, MD and Robert Turner, MD)
on the faculty at UCSF Department of psychiatry proposed
a new diagnostic category to the Task Force preparing
the 4th edition of the DSM which was due to be published
in 1994. We viewed such an addition to the nomenclature
as the most effective way to increase the sensitivity
of mental health professionals to spiritual issues in
therapy. The initial impetus for this proposal came from
the Spiritual Emergence Network (then called the Spiritual
Emergency Network, now the Center for Psychological & Spiritual
Health (CPSH)) which was concerned with the mental health
system's pathologizing approach to intense spiritual
crises.

In December 1991, the proposal for Psychoreligious or
Psychospiritual Problem was formally submitted to the
Task Force on DSM-IV. The proposal stressed the need
for this new diagnosis to improve the cultural sensitivity
of the DSM-IV and also argued that the adoption of this
new category would result in the following benefits:

increasing
the accuracy of diagnostic assessments when religious
and spiritual issues are involvedreducing the
occurrence of iatrogenic harm from misdiagnosis of religious and
spiritual problems improving treatment
of such problems by stimulating clinical research improving treatment
of such problems by encouraging training centers to address religious
and spiritual issues in their programs

Support for the proposal was obtained from the American
Psychiatric Association Committee on Religion and Psychiatry
and the NIMH Workgroup on Culture and Diagnosis. The
proposal in its entirety documenting the need for such
a category was published in the Journal of Nervous and
Mental Disease (Lukoff,
Lu & Turner, 1992) .

In January 1993, the Task Force accepted the proposal
but changed the title to "Religious or Spiritual Problem" and
shortened and modified the definition to read:

V62.89: This category can be used when the focus
of clinical attention is a religious or spiritual problem.
Examples include distressing experiences that involve
loss or questioning of faith, problems associated with
conversion to a new faith, or questioning of other
spiritual values which may not necessarily be related
to an organized church or religious institution. (American
Psychiatric Association, 1994, p. 685)

Articles on this new category appeared in The New
York Times, San Francisco Chronicle, American
Psychiaric Association Psychiatric News, and
the American Psychological Association Monitor, where
it was described as indicating an important shift in
the mental health profession's stance toward religion
and spirituality.

QUIZ EXERCISE 3:

Religious or Spiritual Problem is a ...

a) type of neurosis

b) type of psychosis

c) a proposed new category for the DSM-V

d) new diagnostic category in the DSM-IV

Record your answers for later insertion into the Quiz.

Nursing and Psychology

Historically the nursing profession has been
more receptive to religion and spirituality. Spiritual
Distress has been a category in the nomenclature of the
National Group for the Classification of Nursing Diagnosis
since 1983 [3].
It is defined as "The state in which the individual
experiences or is at risk of experiencing a disturbance
in his or her belief or value system that is his/her
source of strength and hope." Examples include:

Guilt Inability
to practice religious rituals Conflicts between
religious/spiritual beliefs and the prescribed health regimen Lack of meaning
in life A disruption
in the relationship with one's God Lack of forgiveness
toward a significant other

The mental health nursing journals also include religious
and spiritual factors more frequently than psychiatry
or psychology journals.

Whereas the founder of modern nursing, Florence Nightingale,
taught that spirituality was intrinsic to human experience
and compatible with scientific inquiry, the founder
of modern psychiatry, Sigmund Freud, had a strongly
held view of religion as pathological.

Where differences of age, gender, race, ethnicity,
national origin, religion, sexual orientation, disability,
language, or socioeconomic status significantly affect
psychologists' work concerning particular individuals
or groups, psychologists obtain the training, experience,
consultation, or supervision necessary to ensure the
competence of their services, or they make appropriate
referrals.

Ignorance, countertransference, and lack of skill can
impede the untrained psychologist's ethical provision
of therapeutic services to clients who present with religious
or spiritual problems. Differential diagnosis require
knowledge of the patient's religious subgroup and/or
the nature of acceptable expressions of subculturally
validated forms of religious expression. Allen
Bergin (1980)[4] wrote in the American
Psychologist,

Psychologists' understanding and support of cultural
diversity has been exemplary with respect to race,
gender, and ethnicity but the profession's tolerance
and empathy has not adequately reached the religious
client. (p. 95)

In contrast to psychiatric residency training where
the Accreditation Council for Graduate Medical Education
in 1995 issued "Special Requirements for Residency Training
in Psychiatry" that mandates instruction about gender,
ethnicity, sexual orientation, and religious/spiritual
beliefs, such training is not specifically required in
psychology.

Yet the mental health field is growing more sensitive
to religion and spirituality as important factors in
health and well-being. I concur with the assessment of Michael
Washburn,PhD

There still is a pathologization of anything that
has to do with difficult religious experience. We are
overcoming that, I am pleased to say. There is a growing
appreciation that a passage into spiritual life can
be psychologically very challenging, and that we should
expect it as a common occurrence, and learn better
to understand it so we can deal with it when it happens.
I think we are in a better situation as far as those
possibilities are concerned than we have been in the
past. But there's still some way to go.

References

1 Group for the Advancement
of Psychiatry. (1976). Mysticism: Spiritual quest or
mental disorder. New York: Group for the Advancement
of Psychiatry.